Provider Demographics
NPI:1245514629
Name:PEACOCK, JEFFREY (LAC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 MAIN ST
Mailing Address - Street 2:UNIT D
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5569
Mailing Address - Country:US
Mailing Address - Phone:303-834-9188
Mailing Address - Fax:
Practice Address - Street 1:385 MAIN ST
Practice Address - Street 2:UNIT D
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5569
Practice Address - Country:US
Practice Address - Phone:303-834-9188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU-1722171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist